Original research original
Towards optimizing prostate tissue retrieval following holmium laser enucleation of the prostate (HoLEP): Assessment of two morcellators and review of literature Ahmed M. Elshal, MD; Ramy Mekkawy, MD; Mahmoud Laymon, MD; Ahmed El-Assmy, MD; Ahmed R. El-Nahas, MD Urology and Nephrology Center, Mansoura University, Mansoura, Dakahlia Governorate, Egypt Cite as: Can Urol Assoc J 2015;9(9-10):E618-25. http://dx.doi.org/10.5489/cuaj.3035 Published online September 9, 2015.
Abstract Introduction: We assess different approaches to retrieve the enucleated adenoma after transurethral enucleation of the prostate, particularly using the holmium laser. Methods: A retrospective review through our prospectively maintained database was performed looking for safety and efficacy of two morcellators. The enucleation phase of the holmium laser enucleation of the prostate (HoLEP) was classically performed followed by retrieval of the intravesical adenoma using either the Piranha (Wolf Inc., Knittlingen, Germany) or VersaCut (Lumenis) morcellator. A PubMed-MEDLINE search was conducted for all transurethral enucleation procedures and relevant data regarding methods of prostate tissue retrieval were extracted. Results: Strictly limiting the study to 3 reusable blades with each morcellator, we performed 67 and 55 consecutive procedures with Piranha and VersaCut, respectively. There was no significant difference between the two morcellators regarding perioperative complications, apart from 5 bladder mucosal injuries with the VersaCut (9%). Furthermore, there were similar retrieved tissue weight, mechanical problems-rate, catheter-time and hospital-stay in both morcellators. However, the Piranha morcellator needed significantly less morcellation-time, needed to use cold loop to remove non-morcellated pieces and to score the adenoma by laser for better bite of the adenoma, and had a higher median morcellation-rate 6.2 (rate: 2.8–12) g/min. Despite little reporting on morcellation, we had data on the tissue retrieval rate (2.6 to 6.5 g/min with Piranha and 1.9 to 11 g/min with VersaCut. Furthermore, bladder mucosal injury was reported in 1.4% and 0.7 to 5.7% with Piranha and VersaCut, respectively; bladder perforation with VersaCut was experienced in about 0.1 to 1.5% of patients. Our study is limited by its non-randomization. Conclusion: The Piranha morcellator was the most efficient and safe way to retrieve tissue after a transurethral enucleation of a prostate adenoma.
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Introduction With advancements in the treatment of benign prostatic hyperplasia (BPH), patients are now older and have larger prostates at surgery. In these patients, transurethral enucleation is superior to other techniques.1 Different kinds of energy have been used in the enucleation procedure, including holmium YAG,2 thulium,3 Greenlight laser (532 nm),4 and plasma kinetic energy,5 ending by completely or partially detaching the intravesical adenoma. However, the techniques of prostate tissue retrieval, particularly intravesical morcellation of prostatic adenoma, are poorly evaluated. The transurethral morcellation of intravesical prostate adenoma is a tedious procedure. Many difficulties could be encountered, such as impaired visibility with minor bleeding, variable consistency of the adenoma, and malfunction of reusable blades, especially with large prostates. Furthermore, the morcellation process might come after lengthy enucleation procedure that might oblige the surgeon to postpone it to another session (secondary morcellation).6 Transurethral enucleation of the prostate adenoma using holmium laser (HoLEP) has been extensively studied over the past 15 years. However, safety and efficacy of different approaches used to retrieve the enucleated adenoma have not been studied. Since the invention of the mechanical tissue morcellator in 1996,7 tissue morcellators for different endoscopic surgical procedures have significantly evolved, including those used for transurethral morcellation of intravesical prostate adenoma. There are two popular tissue morcellators. The main differences between them are the type of movement of the cutting blades (guillotine vs. oscillation) and shape of the blade (non-toothed vs. toothed) in the VersaCut (Lumenis Inc.) and Piranha (Wolf Inc., Knittlingen, Germany) morcellators, respectively. Alternatives to tissue morcellators are the mushroom technique8 and mini-laparotomy suprapubic extraction of the enucleated adenoma.9
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Optimizing prostate tissue retrieval after HoLEP
In this study, we used the Versacut and Piranha morcellators for prostate tissue retrieval during HoLEP. We also reviewed the relevant literature.
Methods After obtaining institutional review board approval, we reviewed the data of 122 consecutive HoLEP procedures to assess tissue retrieval between November 2013 and October 2014. A single surgeon (AME), with experience in the HoLEP procedure with at least 30 procedures of morcellation using either morcellator, performed the procedures. This comparative study was initiated based on local administrative request to purchase another morcellator. Patients were admitted for BPH surgery when they had refractory lower urinary tract symptoms and failed medical treatment or if they had an indwelling catheter due to urine retention and failed trial of voiding without a catheter. Patients with a history of previous prostate surgery or with diagnosed prostate cancer were not included in the analysis.
Intervention A 100W Holmium: YAG laser (Versapulse, Lumenis Inc., Santa Clara, CA) and a 550-um end-firing flexible fibre (SlimLineTM 550, Lumenis Inc.) were used. Continuous flow 26Fr resectoscope (Karl Storz, Tuebingen, Germany) was used for all procedures; a connecting piece was used to adapt a rigid indirect long nephroscope (Karl Storz) with a 5-mm working channel through which the morcellator blade passed. Double irrigation sets were used connected to both inflow and outflow channels of the scope. The enucleation phase of HoLEP was performed as previously described.2 Retrieval of the prostate adenoma was performed by trans-
urethral morcellation using either Piranha morcellator (Fig. 1, parts A and C) or the VersaCut (Fig. 1, parts B and D). The morcellator blade was introduced just inside the bladder neck with the blades facing up; the initial suction brings the adenoma over the tip of the blades after which the cutting starts. The blades and the adenoma are kept away from the bladder mucosa to avoid any laceration. Between November 2013 and March 2014, we consecutively performed 55 procedures with the VersaCut morcellator, during which 3 new reusable blades were consumed. Between April 2014 and October 2014, we consecutively performed 67 procedures with the Piranha morcellator, during which 3 new reusable blades were consumed. We tallied every case and marked every single blade. Moreover, all peri-procedural parameters were recorded and the surgeon determined whether any blades were non-usable. All morcellation auxiliary procedures were recorded. Auxiliary procedures included the use of a crown loop (toothed cold loop, Fig. 1, parts E and F) to extract nonmorcellated pieces or the use of a laser to score hardly bitten adenomas by the blade. Postoperatively, a 22Fr tri-way urethral catheter was fixed. Most patients were discharged the next day.
Primary outcome measures Operative efficacy parameters were reported and compared. Efficacy parameters included the time and rate of tissue retrieval procedure, weight of the tissue retrieved and overall operative time. Time of tissue retrieval was defined as the time from introduction of the morcellator blade to the bladder until extraction of the last piece of the prostatic adenoma. The rate of retrieval was calculated by dividing the weight of the prostate specimen by the time needed for retrieval.
Secondary outcome measures Perioperative complications (safety) were reported and compared. Morcellation-related complications, namely bladder injury and peri-procedural bleeding, were com-
Fig. 1a. Blade of pirnha morcellator.
Fig. 1b. Blade of versacut morcellator.
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Fig. 1d. Blade of versacut morcellator in action.
for the tissue retrieval rate and two-tailed significance, we achieved a computed power of 90%.
Fig. 1c. Blade of pirnha morcellator in action.
pared. Hospital stay and catheter time were recorded and compared.
Statistical analysis Data analysis was conducted using the commercially available Statistical Package for Social Sciences (SPSS 20 for Mac, SAS Institute, Cary, NC). Results were compared between study groups using the Chi-square and Fisher’s exact tests for categorical variables and the independent samples t-test and Mann-Whitney U-test for quantitative variables as appropriate. Using post-hoc analysis for the studied sample, considering type 1 statistical error less than 0.05, effect size of 0.6
Fig. 1e. Crown loop.
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Review of literature We searched PubMed-MEDLINE for English-based literature using medical subject headings including benign prostatic hyperplasia (BPH), enlargement (BPE), and obstruction (BPO); minimal invasive surgery; and the specific MIST and TURP name looking for all transurethral prostate enucleation techniques. Reference lists of all depicted articles were reviewed for relevant reports. Different articles based on the same patient cohort with different follow-up duration and/or outcome measures were considered a single study, and all relevant data regarding methods of prostate tissue retrieval were extracted.
Fig. 1f. Crown loop in the bladder to extract non morcellated adenomas.
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Table 1. Efficacy assessment No. procedures Median, range tissue retrieval time (min) Histopathology; median, range of weight of specimen (g) BPH (%) BPH with prostatitis (%) BPH with focal prostate cancer (%) Median, range of tissue retrieval rate (g/min) [specimen weight/retrieval time] Use of crown loop* for extraction of nonmorcellated parts (%) Laser scoring of the adenoma to ease bite by the blade (%) Intraoperative morcellator mechanical problems (%) Median, range of catheterization time (days) Median, range of Hospital stay (days)
Table 2. Peri-procedure safety profile
Piranha¥ 67
VersaCut† 55
p value
20 (5:30)
25 (5:70)
0.04
67 (23:230)
62 (14:189)
0.07
65 (97) –
50 (92) 2 (3.6)
0.34
2 (3)
3 (5.4)
6.2 (2.8:12)
2.13 (0.46:7)
0.00
No. procedures Bleeding necessitating post retrieval hemostasis (%) Median, range of Hemoglobin deficit* (g/dL) Median, range of Hematocrit value deficit* (%) Median, range of Blood sodium deficit* (mmol/L) Bladder injury (%) Bladder mucosal injury Bladder perforation Postoperative hematuria (%)
Piranha¥
VersaCut†
67
55
1 (1.4)
5 (9)
0.06
1.5 (0.1:3.7)
0.2
4.3 (-7.9:20.2)
0.8
1.5 (1:2.1)
3 (-8.7:11.6)
0.7
– – 4 (2.9)
5 (9) – 2 (3.6)
0.01
1.2 (0.1:4.8) 4.3 (-1.6:14.7)
p value
0.19
*Preoperative minus immediate postoperative value. ¥Piranha, Wolf Inc., Knittlingen, Germany; †VersaCut, Lumenis.
4 (5.9)
17 (30.9)
0.00
–
7
0.00
7 (10.4)
2 (3.6)
0.2
1 (1:5)
1 (1:3)
0.3
1 (1:3)
1 (1:4)
0.08
*Crown loop; toothed cold loop. BPH: benign prostatic hyperplasia; NA: not applicable. ¥Piranha, Wolf Inc., Knittlingen, Germany; †VersaCut, Lumenis.
Results Following Holmium laser-assisted enucleation of the prostate adenoma, the Piranha morcellator was used in 67 procedures and the VersaCut morcellator in 55 procedures. The preoperative prostate size was similar in both morcellators (median [range] transurethral resection of the prostate estimated prostate size was 130 [ranage: 59–295] and 114 [range: 46–345] mL with Piranha and VersaCut morcellators, respectively, p = 0.1). Histopathologic findings of the retrieved prostate tissues were not different between the two morcellators. Significantly more prostate tissue retrieval time and need of morcellation auxiliary procedures were reported with the VersaCut morcellator (Table 1). The median tissue retrieval rate was 6.2 (range: 2.8–12) and 2.13 (0.46–7) g/min with the Piranha and VersaCut morcellators, respectively (p = 0.001). Similar retrieved tissue weight and catheter time were reported in both morcellators (Table 1). The median number of procedures done per blade was 22 (range: 20–25) and 18 (17–20) with the Piranha and VersaCut morcellators, respectively (p = 0.01). The median number of grams of prostate tissue retrieved per blade was 1499 (range: 1388–1539) and 943 (833–1248) with the Piranha and VersaCut morcellators, respectively (p = 0.04).
There was no significant difference between the two morcellators regarding perioperative biochemical changes and complications, apart from 5 bladder mucosal injuries in the VersaCut group (9%) (Table 2). Table 3 summarizes the tissue retrieval approaches used in contemporary series of different transurethral enucleation procedures. Data on preoperative prostate size, retrieved prostate weight, rate of tissue retrieval and possible complications related to the procedure of retrieval namely bleeding and bladder injury were tallied. Furthermore, findings of incidental prostate cancer and history of prior prostate surgery were depicted for possible impact on prostate tissue consistency.3-6,8,10-27
Discussion The transurethral enucleation of prostate adenoma carries the advantage of doing an anatomical based de-obstruction, which further to being complete is safer by tackling the vascular supply once it goes to the adenoma. Many competing techniques using different energy sources (electric and different lasers) to accomplish the enucleation procedure have been reported.2-5 However, retrieval of the adenoma after transurethral enucleation remains poorly evaluated. Transurethral resection of partially detached adenoma is not advantageous as it can induce more risk of bleeding, impaired visibility and is time consuming, especially for large prostates where the transurethral enucleation is superior to other minimally invasive surgeries. Morcellation of intravesical adenoma is currently the standard procedure following most transurethral enucleation procedures; however it is poorly evaluated. It is not complication-free and might require the surgeon to stage the procedure (secondary morcellation due to bleeding or blade malfunction).6 In our current study, we presented the current viable approaches used to retrieve the enucleated prostate ade-
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75.8 ± 29.7 NR
HoLEP
HoLEP
Piranha morcellator Piranha morcellator Morcellator (NR) Bipolar Mushroom
84.8 ± 34.9 51 (36–78) 59.9 ± 15.4 [34–89] 75 ± 38 77.3 [56–95]
ThulEP
ThulEP
ELEP
Greenlight LEP
PKEP
ThulEP
HoLEP
U; 54 ± 22 I; 53.6±20 43.5 ± 23 [37.3-76.4] 46.6 ± 25.2 [34.2-79.6]
HoLEP “up [U] & Inverse tech [I]”
Piranha morcellator
Unipolar Mushroom
Unipolar Mushroom
VersaCut morcellator
VersaCut morcellator
62 ± 34
HoLEP
Unipolar Mushroom
Unipolar Mushroom 83% VersaCut morcellator 17%
53.5 ± 20 [20–95]
114.6± 21 [100–230]
VersaCut morcellator OC 0.2% VersaCut morcellator OC 0.1%
VersaCut morcellator
VersaCut morcellator
VersaCut morcellator
VersaCut morcellator OC 0.3%
Unipolar Mushroom
Tissue retrieval approach
HoLEP
HoLEP
86.5 ± 65.4 [20–350]
G1; 94.3 G2; 79.3 G1; 93 ± 47 G2; 96 ± 46 B; 88.1 T; 100.4
G1 (HoLEP) G2 (2ry HoLEP) G1 (2ry HoLEP) G2 (HoLEP) HoLEP B and T
HoLEP
38 [20–70]
HoLEP
Procedure
51 ± 14.3
35 ± 22
32.20 ± 9.36
NR
NR
20.31 ± 6.62
11 (8–20)
NR
53.68 ± 29.9 [5 -147] 30 (16–51.25)
NR
NR
U: 14.3 ± 8.6 I: 6.4 ± 7.2
17.3 ± 14.5
NR
NR
19.3 ± 10.1 [4–45]
NR
G1: 16.9 G2: 16.6 G1: 19.8 ± 20 G2: 14.9 ± 11 B: 4.8 ± 2 T: 5 ± 3.6 17.6 ± 9.7 [5–65]
NR
37.6 ± 12.1
40.4 ± 10.6
NR
40 ± 27.5
32.6 ± 15.0 [10–80]
83.9 ± 21.9 [52–200]
G1: 64.5 G2: 52.6 G1: 61.7 ± 40 G2: 63.9 ± 42 B: 50 ± 49.5 T: 56 ± 41.8 46.7 ± 27 [7-152] 76 [0.4– 532.2] 78.6 ± 61.3 [10-350]
NR
Retrieved Retrieval time tissue weight (mean + SD (mean + SD [range] min) [range] g)
NR
NR
NR
2.6 (1.7–4)
NR
NR
NR
U: 1.93 ± 1.1 I: 4.03 ± 0.89
2.3 ± 1.5
NR
NR
4.07 ± 3.2
NR
G1: 3.81 G2: 3.16 G1: 4 ± 2 G2: 5 ± 2.5 B: 10.4 ± 24 T: 11.2 ± 11 2.8± 1 [0.9– 10.1]
NR
Retrieval rate (mean ± SD [range] g/min)
NR
1.5%
6.9%
NR
NR
NR
2.4%
NR
5%
4.4%
0.6%
0.8%
1.3%
G1: 2.7%
G1: 0.2% G2: 1.3
NR
Bleeding
NR
NR
Zero
NR
Zero
5.5%
1.4% (Mucosal) NR
14.1%
NR
NR
NR
3.6%
3%
5%
1.7%
10%
4.8%
NR
NR
NR
3.2%
T1a-b PCa (%)
NR
NR
NR
2.3% (Mucosal) 1.5% (Perforation)
5.7% (Mucosal)
NR
NR
NR
0.1% (Perforation)
4% (Mucosal)
0.3% (Perforation)
NR
0.7% (Mucosal)
NR
Bladder injury
Retrieval approach related Complication
RCT; randomized clinical trials, CS; case series, HoLEP; Holmium laser enucleation of the prostate, 2ndry HoLEP; after previous prostate surgery, ThulEP; Thulium laser enucleation of the prostate, Greenlight LEP; Greenlight laser enucleation of the prostate, ELEP; Eraser laser enucleation of the prostate, PKEP; Plasma kinetic enucleation of the prostate, NS; not specified, NR; not reported, NA; not applicable, PCa; prostate cancer, OC; open cystostomy; B: bilop; T: trilob; Piranha, Wolf Inc., Knittlingen, Germany; †VersaCut, Lumenis.
Kuntz et al 200417 (RCT) Vavassori et al 200818 (CS) Lee et al 201227 (CS) Zhang et al 201219 (RCT) Zhang et al 201219 (RCT) Rausch et al 20153 (RCT) Gross et al 20136 (CS) Hruby et al 201320 (CS) Brunken et al 20114 (CS) Liao et al 201226 (CS)
Kuntz et al 200216 (RCT)
Hochreiter et al 20028 (CS) Elshal et al10 2012 (CS) Jaeger et al11 2013 (CS) Wisenbaugh et al 201313 (CS) Placer et al 200914 (CS) Krambeck et al 201012 (CS) Abdel-Hakim et al 201015 (CS)
Study (RCT/CS)
Prostate size (mean ± SD [range] mL)
Table 3. Critical evaluation of prostate tissue retrieval approaches following different transurethral enucleation techniques in the contemporary series
Elshal et al.
NR NR NR 65.9 ± 20.8 116.2 ± 32 PKEP
Bipolar Mushroom
NR NR Bipolar Mushroom 110 [102–130] PKEP
118.2 ± 22.0
NR NR 64.2 ± 19.0 Bipolar Mushroom 113.8 ± 32
PKEP
PKEP
Piranha morcellator
108 [58–241]
16.5
6.56
2.9%
NR
NR
NR NR NR 56.4 ± 1 2.8 [32–102] Bipolar Mushroom
69.2 ± 13.5 [35–158] 132.6 [80–280] PKEP
RCT; randomized clinical trials, CS; case series, HoLEP; Holmium laser enucleation of the prostate, 2ndry HoLEP; after previous prostate surgery, ThulEP; Thulium laser enucleation of the prostate, Greenlight LEP; Greenlight laser enucleation of the prostate, ELEP; Eraser laser enucleation of the prostate, PKEP; Plasma kinetic enucleation of the prostate, NS; not specified, NR; not reported, NA; not applicable, PCa; prostate cancer, OC; open cystostomy; B: bilop; T: trilob; Piranha, Wolf Inc., Knittlingen, Germany; †VersaCut, Lumenis.
NR
1.25%
NR
2.8% NR
NR
NR NR NR 46.2 ± 19.1 Bipolar Mushroom 61.8 ± 18.7 PKEP
Luo et al 201422 (CS) Zhao et al 201024 (RCT) Geavlete et al 20135 (RCT) Zhu et al 201325 (RCT) Chen et al 201421 (RCT) Rao et al 201323 (RCT)
Tissue retrieval approach Procedure Study (RCT/CS)
NR
Bleeding
Bladder injury
T1a-b PCa (%) Retrieval approach related Complication
Retrieval rate (mean ± SD [range] g/min) Retrieved Retrieval time tissue weight (mean + SD (mean + SD [range] min) [range] g) Prostate size (mean ± SD [range] mL)
Table 3. Critical evaluation of prostate tissue retrieval approaches following different transurethral enucleation techniques in the contemporary series (cont’d)
Optimizing prostate tissue retrieval after HoLEP
noma following holmium laser enucleation. We compared safety and efficacy of two commercially available morcellators that have not been previously clinically compared. A single surgeon, with HoLEP experience with at least 30 morcellations using either morcellator, performed the procedures. A minimum of 20 cases are required to achieve morcellation efficiency.28 In an ex-vivo study, the efficiency of different morcellators were assessed. The Piranha morcellated 20 (range: 19.3–21.4) g/min, the VersaCut 10.8 (range: 8.2–13.1) g/min, Karl Storz prototype 9.8 (range: 7.9–10.76) g/min, and another Wolf prototype 38.6 (35.3–42.9) g/min.29 Another ex-vivo study looking at different efficiency parameters of the Piranha and VersaCut morcellators revealed similar suction power parameters (20.4 and 22.2 mL/s, respectively). Morcellating powers were (example with baked chicken meat) 2.5 and 6 g/min with Piranha and VersaCut, respectively.30 In the current study, the median rate of tissue retrieval was 6.2 (range: 2.8–12) and 2.13 (range: 0.46–7) g/min with Piranha and VersaCut morcellators, respectively. The literature demonstrated tissue retrieval rates of 2.6 to 6.5 and 1.9 to 11 g/min with Piranha and VersaCut morcellators, respectively (Table 3); however, there is little data on the details of morcellation in clinical reports of transurethral enucleation procedures. The safety of morcellator is a crucial part of the assessment in our current study; superficial bladder mucosal injury was reported in 9% of procedures with the VersaCut morcellator. Superficial bladder mucosal injury was reported in 1.4% and 0.7 to 5.7% with Piranha and VersaCut morcellators, respectively; there were bladder perforations with the VersaCut morcellator (range: 0.1–1.5%) (Table 3). In their ex-vivo study, Cornu and colleagues showed that the blade of the Pirhana morcellator was under visual control, whereas the distal part of the cutting blade was out of vision control with the VersaCut.30 The efficiency of tissue retrieval by a morcellator is a sum of multiple variables, including prostate tissue consistency, suction power, and morcellator blade. Prior prostate surgery and histopathological features of the adenoma probably affect prostate tissue consistency. Other non-morcellation approaches have been used in many of the reported transurethral enucleation techniques, as a routine practice (like using mushroom technique after most bipolar enucleation techniques5,23,26 and, to a lesser extent, after HoLEP8,16,17) or occasional in cases of morcellator malfunction or for exceptionally huge adenomas where some surgeons perform an open cystostomy for adenoma extraction.10 The morcellator action is to cut and suck. Most of mechanical problems reported in this study were related to suction. In the Piranha morcellator, suction depends on creating negative pressure within a vacuum bottle. Problems
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occurred secondary to leak of negative pressure from the vacuum bottle/ tubing set. This requires the surgeon to stop to recreate the required negative pressure. In the VersaCut morcellator, suction depends on a high-suction roller pump; obstruction of the tubing set with large tissue piece causes malfunction of the pump and significantly reduces suction power. This also requires the surgeon to stop and reverse direction of flow for a while to clean the tubing set. Lastly, regarding the technique of transurethral morcellation, we used the conventional upward technique. A modification of the technique to increase morcellation efficiency and to lessen the incidence of bladder injury is called “the inverse technique.”27 It entails sucking the adenoma toward the blades then inversely rotating the nephroscope and the blades, with the blade openings pointing inferior toward the bladder and superior to the prostate tissue. Lee and colleagues reported a higher rate of tissue retrieval with their technique using the VersaCut morcellator.27 Superficial (7.1% and 0.9%) and deep bladder injuries in (5.9% and 0.3%) were reported in conventional and inverse techniques, respectively (Table 3). Our study has its limitations. In terms of evidence, this study lacks randomization. However, we found that randomization was not practical for an in depth evaluation of all aspects of morcellation, including reusable blade efficiency (e.g., surgeons prefer using new or minimally used blades when tackling significantly large glands). So, we assigned 3 blades for each morcellator group for the study, with careful reporting of all peri-procedure parameters.
Conclusion Morcellation with the Piranha morcellator was the most efficient and safe way to retrieve tissue following transurethral enucleation of prostate adenoma during BPH treatment. Detailed reporting of the morcellation step is recommended in any report of a transurethral enucleation technique. Competing interests: The authors declare no competing financial or personal interests.
This paper has been peer-reviewed.
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4. Brunken C, Seitz C, Tauber S, et al. Transurethral GreenLight laser enucleation of the prostate--a feasibility study. J Endourol 2011;25:1199-201. http://dx.doi.org/10.1089/end.2010.0550 5. Geavlete B, Stanescu F, Iacoboaie C, et al. Bipolar plasma enucleation of the prostate vs open prostatectomy in large benign prostatic hyperplasia cases - a medium term, prospective, randomized comparison. BJU Int 2013;111:793-803. http://dx.doi.org/10.1111/j.1464-410X.2012.11730.x 6. Gross AJ, Netsch C, Knipper S, et al. Complications and early postoperative outcome in 1080 patients after thulium vapoenucleation of the prostate: Results at a single institution. Eur Urol 2013;63:859-67. http://dx.doi.org/10.1016/j.eururo.2012.11.048 7. Sauer JS, Greenwald RJ, Bovard MA, et al. Morcellator. US Patent 5562694. Issue date: Oct 8, 1996. 8. Hochreiter WW, Thalmann GN, Burkhard FC, et al. Holmium laser enucleation of the prostate combined with electrocautery resection: the mushroom technique. J Urol 2002;168:1470-4. http://dx.doi. org/10.1016/S0022-5347(05)64476-X 9. Yu XX, Zhang RM, Zhou DQ, et al. Transurethral plasmakinetic enucleation of prostate and suprapubic small cut in the treatment of high risk and senior patient with benign prostatic hyperplasia and bladder stones [in Chinese]. Zhonghua yi xue za zhi 2013;93:597-9. 10. Elshal AM, Elmansy HM, Elhilali MM. Feasibility of holmium laser enucleation of the prostate (HoLEP) for recurrent/ residual benign prostate hyperplasia (BPH). BJU Int 2012;110:E845-50. http://dx.doi. org/10.1111/j.1464-410X.2012.11290.x 11. Jaeger CD, Krambeck AE. Holmium laser enucleation of the prostate for persistent lower urinary tract Symptoms after prior benign prostatic hyperplasia surgery. Urology 2013;81:1025-9. http://dx.doi. org/10.1016/j.urology.2013.01.019 12. Krambeck AE, Handa SE, Lingeman JE. Experience with more than 1,000 holmium laser prostate enucleations for benign prostatic hyperplasia. J Urol 2010;183:1105-9. http://dx.doi.org/10.1016/j. juro.2009.11.034 13. Wisenbaugh ES, Nunez-Nateras R, Mmeje CO, et al. Does prostate morphology affect outcomes after holmium laser enucleation? Urology 2013;81:844-8. http://dx.doi.org/10.1016/j.urology.2013.01.006 14. Placer J, Gelabert-Mas A, Vallmanya F, et al. Holmium laser enucleation of prostate: Outcome and complications of self-taught learning curve. Urology 2009;73:1042-8. http://dx.doi.org/10.1016/j. urology.2008.12.052 15. Abdel-Hakim AM, Habib EI, El-Feel AS, et al. Holmium laser enucleation of the prostate: Initial report of the first 230 Egyptian cases performed in a single center. Urology 2010;76:448-52. http://dx.doi. org/10.1016/j.urology.2009.12.035 16. Kuntz RM, Lehrich K. Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100 gm: A randomized prospective trial of 120 patients. J Urol 2002;168:1465-9. http://dx.doi.org/10.1016/S0022-5347(05)64475-8 17. Kuntz RM, Ahyai S, Lehrich K, et al. Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: A randomized prospective trial in 200 patients. J Urol 2004;172:1012-6. http://dx.doi.org/10.1097/01.ju.0000136218.11998.9e 18. Vavassori I, Valenti S, Naspro R, et al. Three-year outcome following holmium laser enucleation of the prostate combined with mechanical morcellation in 330 consecutive patients. Eur Urol 2008;53:599-604. http://dx.doi.org/10.1016/j.eururo.2007.10.059 19. Zhang F, Shao Q, Herrmann TR, et al. Thulium laser versus holmium laser transurethral enucleation of the prostate: 18-month follow-up data of a single center. Urology 2012;79:869-74. http://dx.doi. org/10.1016/j.urology.2011.12.018 20. Hruby S, Sieberer M, Schatz T, et al. Eraser laser enucleation of the prostate: Technique and results. Eur Urol 2013;63:341-6. http://dx.doi.org/10.1016/j.eururo.2012.08.049 21. Chen S, Zhu L, Cai J, et al. Plasmakinetic enucleation of the prostate compared with open prostatectomy for prostates larger than 100 grams: A randomized noninferiority controlled trial with long-term results at 6 years. Eur Urol 2014;66:284-91. http://dx.doi.org/10.1016/j.eururo.2014.01.010 22. Luo YH, Shen JH, Guan RY, et al. Plasmakinetic enucleation of the prostate vs plasmakinetic resection of the prostate for benign prostatic hyperplasia: Comparison of outcomes according to prostate size in 310 patients. Urology 2014;84:904-10. http://dx.doi.org/10.1016/j.urology.2014.06.025 23. Rao JM, Yang JR, Ren YX, et al. Plasmakinetic enucleation of the prostate versus transvesical open prostatectomy for benign prostatic hyperplasia >80 mL: 12-month follow-up results of a randomized clinical trial. Urology 2013;82:176-81. http://dx.doi.org/10.1016/j.urology.2013.02.032 24. Zhao Z, Zeng G, Zhong W, et al. A prospective, randomised trial comparing plasmakinetic enucleation to standard transurethral resection of the prostate for symptomatic benign prostatic hyperplasia: Threeyear follow-up results. Eur Urol 2010;58:752-8. http://dx.doi.org/10.1016/j.eururo.2010.08.026 25. Zhu L, Chen S, Yang S, et al. Electrosurgical enucleation versus bipolar transurethral resection for prostates larger than 70 ml: A prospective, randomized trial with 5-year followup. J Urol 2013;189:1427-31. http://dx.doi.org/10.1016/j.juro.2012.10.117 26. Liao N, Yu J. A study comparing plasmakinetic enucleation with bipolar plasmakinetic resection of the prostate for benign prostatic hyperplasia. J Endourol 2012;26:884-8. http://dx.doi.org/10.1089/ end.2011.0358
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Optimizing prostate tissue retrieval after HoLEP
27. Lee SH, Choi JI, Moon KY, et al. Holmium laser enucleation of the prostate: Modified morcellation technique and results. Korean J Urol 2012;53:779-84. http://dx.doi.org/10.4111/kju.2012.53.11.779 28. Bae J, Oh SJ, Paick JS. The learning curve for holmium laser enucleation of the prostate: A single-center experience. Korean J Urol 2010;51:688-93. http://dx.doi.org/10.4111/kju.2010.51.10.688 29. Ritter M, Krombach P, Bolenz C, et al. Standardized comparison of prostate morcellators using a new ex-vivo model. J Endourol 2012;26:697-700. http://dx.doi.org/10.1089/end.2011.0536
30. Cornu JN, Terrasa JB, Lukacs B. Ex vivo comparison of available morcellation devices during holmium laser enucleation of the prostate through objective parameters. J Endoruol 2014;28:1237-40. http:// dx.doi.org/10.1089/end.2011.0454
Correspondence: Dr. Ahmed M. Elshal, Urology and Nephrology Center, Mansoura University, Mansoura, Dakahlia Governorate, Egypt; [email protected]
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Towards optimizing prostate tissue retrieval following holmium laser enucleation of the prostate (HoLEP): Assessment of two morcellators and review of literature Ahmed M. Elshal, MD; Ramy Mekkawy, MD; Mahmoud Laymon, MD; Ahmed El-Assmy, MD; Ahmed R. El-Nahas, MD Urology and Nephrology Center, Mansoura University, Mansoura, Dakahlia Governorate, Egypt Cite as: Can Urol Assoc J 2015;9(9-10):E618-25. http://dx.doi.org/10.5489/cuaj.3035 Published online September 9, 2015.
Abstract Introduction: We assess different approaches to retrieve the enucleated adenoma after transurethral enucleation of the prostate, particularly using the holmium laser. Methods: A retrospective review through our prospectively maintained database was performed looking for safety and efficacy of two morcellators. The enucleation phase of the holmium laser enucleation of the prostate (HoLEP) was classically performed followed by retrieval of the intravesical adenoma using either the Piranha (Wolf Inc., Knittlingen, Germany) or VersaCut (Lumenis) morcellator. A PubMed-MEDLINE search was conducted for all transurethral enucleation procedures and relevant data regarding methods of prostate tissue retrieval were extracted. Results: Strictly limiting the study to 3 reusable blades with each morcellator, we performed 67 and 55 consecutive procedures with Piranha and VersaCut, respectively. There was no significant difference between the two morcellators regarding perioperative complications, apart from 5 bladder mucosal injuries with the VersaCut (9%). Furthermore, there were similar retrieved tissue weight, mechanical problems-rate, catheter-time and hospital-stay in both morcellators. However, the Piranha morcellator needed significantly less morcellation-time, needed to use cold loop to remove non-morcellated pieces and to score the adenoma by laser for better bite of the adenoma, and had a higher median morcellation-rate 6.2 (rate: 2.8–12) g/min. Despite little reporting on morcellation, we had data on the tissue retrieval rate (2.6 to 6.5 g/min with Piranha and 1.9 to 11 g/min with VersaCut. Furthermore, bladder mucosal injury was reported in 1.4% and 0.7 to 5.7% with Piranha and VersaCut, respectively; bladder perforation with VersaCut was experienced in about 0.1 to 1.5% of patients. Our study is limited by its non-randomization. Conclusion: The Piranha morcellator was the most efficient and safe way to retrieve tissue after a transurethral enucleation of a prostate adenoma.
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Introduction With advancements in the treatment of benign prostatic hyperplasia (BPH), patients are now older and have larger prostates at surgery. In these patients, transurethral enucleation is superior to other techniques.1 Different kinds of energy have been used in the enucleation procedure, including holmium YAG,2 thulium,3 Greenlight laser (532 nm),4 and plasma kinetic energy,5 ending by completely or partially detaching the intravesical adenoma. However, the techniques of prostate tissue retrieval, particularly intravesical morcellation of prostatic adenoma, are poorly evaluated. The transurethral morcellation of intravesical prostate adenoma is a tedious procedure. Many difficulties could be encountered, such as impaired visibility with minor bleeding, variable consistency of the adenoma, and malfunction of reusable blades, especially with large prostates. Furthermore, the morcellation process might come after lengthy enucleation procedure that might oblige the surgeon to postpone it to another session (secondary morcellation).6 Transurethral enucleation of the prostate adenoma using holmium laser (HoLEP) has been extensively studied over the past 15 years. However, safety and efficacy of different approaches used to retrieve the enucleated adenoma have not been studied. Since the invention of the mechanical tissue morcellator in 1996,7 tissue morcellators for different endoscopic surgical procedures have significantly evolved, including those used for transurethral morcellation of intravesical prostate adenoma. There are two popular tissue morcellators. The main differences between them are the type of movement of the cutting blades (guillotine vs. oscillation) and shape of the blade (non-toothed vs. toothed) in the VersaCut (Lumenis Inc.) and Piranha (Wolf Inc., Knittlingen, Germany) morcellators, respectively. Alternatives to tissue morcellators are the mushroom technique8 and mini-laparotomy suprapubic extraction of the enucleated adenoma.9
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Optimizing prostate tissue retrieval after HoLEP
In this study, we used the Versacut and Piranha morcellators for prostate tissue retrieval during HoLEP. We also reviewed the relevant literature.
Methods After obtaining institutional review board approval, we reviewed the data of 122 consecutive HoLEP procedures to assess tissue retrieval between November 2013 and October 2014. A single surgeon (AME), with experience in the HoLEP procedure with at least 30 procedures of morcellation using either morcellator, performed the procedures. This comparative study was initiated based on local administrative request to purchase another morcellator. Patients were admitted for BPH surgery when they had refractory lower urinary tract symptoms and failed medical treatment or if they had an indwelling catheter due to urine retention and failed trial of voiding without a catheter. Patients with a history of previous prostate surgery or with diagnosed prostate cancer were not included in the analysis.
Intervention A 100W Holmium: YAG laser (Versapulse, Lumenis Inc., Santa Clara, CA) and a 550-um end-firing flexible fibre (SlimLineTM 550, Lumenis Inc.) were used. Continuous flow 26Fr resectoscope (Karl Storz, Tuebingen, Germany) was used for all procedures; a connecting piece was used to adapt a rigid indirect long nephroscope (Karl Storz) with a 5-mm working channel through which the morcellator blade passed. Double irrigation sets were used connected to both inflow and outflow channels of the scope. The enucleation phase of HoLEP was performed as previously described.2 Retrieval of the prostate adenoma was performed by trans-
urethral morcellation using either Piranha morcellator (Fig. 1, parts A and C) or the VersaCut (Fig. 1, parts B and D). The morcellator blade was introduced just inside the bladder neck with the blades facing up; the initial suction brings the adenoma over the tip of the blades after which the cutting starts. The blades and the adenoma are kept away from the bladder mucosa to avoid any laceration. Between November 2013 and March 2014, we consecutively performed 55 procedures with the VersaCut morcellator, during which 3 new reusable blades were consumed. Between April 2014 and October 2014, we consecutively performed 67 procedures with the Piranha morcellator, during which 3 new reusable blades were consumed. We tallied every case and marked every single blade. Moreover, all peri-procedural parameters were recorded and the surgeon determined whether any blades were non-usable. All morcellation auxiliary procedures were recorded. Auxiliary procedures included the use of a crown loop (toothed cold loop, Fig. 1, parts E and F) to extract nonmorcellated pieces or the use of a laser to score hardly bitten adenomas by the blade. Postoperatively, a 22Fr tri-way urethral catheter was fixed. Most patients were discharged the next day.
Primary outcome measures Operative efficacy parameters were reported and compared. Efficacy parameters included the time and rate of tissue retrieval procedure, weight of the tissue retrieved and overall operative time. Time of tissue retrieval was defined as the time from introduction of the morcellator blade to the bladder until extraction of the last piece of the prostatic adenoma. The rate of retrieval was calculated by dividing the weight of the prostate specimen by the time needed for retrieval.
Secondary outcome measures Perioperative complications (safety) were reported and compared. Morcellation-related complications, namely bladder injury and peri-procedural bleeding, were com-
Fig. 1a. Blade of pirnha morcellator.
Fig. 1b. Blade of versacut morcellator.
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Fig. 1d. Blade of versacut morcellator in action.
for the tissue retrieval rate and two-tailed significance, we achieved a computed power of 90%.
Fig. 1c. Blade of pirnha morcellator in action.
pared. Hospital stay and catheter time were recorded and compared.
Statistical analysis Data analysis was conducted using the commercially available Statistical Package for Social Sciences (SPSS 20 for Mac, SAS Institute, Cary, NC). Results were compared between study groups using the Chi-square and Fisher’s exact tests for categorical variables and the independent samples t-test and Mann-Whitney U-test for quantitative variables as appropriate. Using post-hoc analysis for the studied sample, considering type 1 statistical error less than 0.05, effect size of 0.6
Fig. 1e. Crown loop.
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Review of literature We searched PubMed-MEDLINE for English-based literature using medical subject headings including benign prostatic hyperplasia (BPH), enlargement (BPE), and obstruction (BPO); minimal invasive surgery; and the specific MIST and TURP name looking for all transurethral prostate enucleation techniques. Reference lists of all depicted articles were reviewed for relevant reports. Different articles based on the same patient cohort with different follow-up duration and/or outcome measures were considered a single study, and all relevant data regarding methods of prostate tissue retrieval were extracted.
Fig. 1f. Crown loop in the bladder to extract non morcellated adenomas.
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Table 1. Efficacy assessment No. procedures Median, range tissue retrieval time (min) Histopathology; median, range of weight of specimen (g) BPH (%) BPH with prostatitis (%) BPH with focal prostate cancer (%) Median, range of tissue retrieval rate (g/min) [specimen weight/retrieval time] Use of crown loop* for extraction of nonmorcellated parts (%) Laser scoring of the adenoma to ease bite by the blade (%) Intraoperative morcellator mechanical problems (%) Median, range of catheterization time (days) Median, range of Hospital stay (days)
Table 2. Peri-procedure safety profile
Piranha¥ 67
VersaCut† 55
p value
20 (5:30)
25 (5:70)
0.04
67 (23:230)
62 (14:189)
0.07
65 (97) –
50 (92) 2 (3.6)
0.34
2 (3)
3 (5.4)
6.2 (2.8:12)
2.13 (0.46:7)
0.00
No. procedures Bleeding necessitating post retrieval hemostasis (%) Median, range of Hemoglobin deficit* (g/dL) Median, range of Hematocrit value deficit* (%) Median, range of Blood sodium deficit* (mmol/L) Bladder injury (%) Bladder mucosal injury Bladder perforation Postoperative hematuria (%)
Piranha¥
VersaCut†
67
55
1 (1.4)
5 (9)
0.06
1.5 (0.1:3.7)
0.2
4.3 (-7.9:20.2)
0.8
1.5 (1:2.1)
3 (-8.7:11.6)
0.7
– – 4 (2.9)
5 (9) – 2 (3.6)
0.01
1.2 (0.1:4.8) 4.3 (-1.6:14.7)
p value
0.19
*Preoperative minus immediate postoperative value. ¥Piranha, Wolf Inc., Knittlingen, Germany; †VersaCut, Lumenis.
4 (5.9)
17 (30.9)
0.00
–
7
0.00
7 (10.4)
2 (3.6)
0.2
1 (1:5)
1 (1:3)
0.3
1 (1:3)
1 (1:4)
0.08
*Crown loop; toothed cold loop. BPH: benign prostatic hyperplasia; NA: not applicable. ¥Piranha, Wolf Inc., Knittlingen, Germany; †VersaCut, Lumenis.
Results Following Holmium laser-assisted enucleation of the prostate adenoma, the Piranha morcellator was used in 67 procedures and the VersaCut morcellator in 55 procedures. The preoperative prostate size was similar in both morcellators (median [range] transurethral resection of the prostate estimated prostate size was 130 [ranage: 59–295] and 114 [range: 46–345] mL with Piranha and VersaCut morcellators, respectively, p = 0.1). Histopathologic findings of the retrieved prostate tissues were not different between the two morcellators. Significantly more prostate tissue retrieval time and need of morcellation auxiliary procedures were reported with the VersaCut morcellator (Table 1). The median tissue retrieval rate was 6.2 (range: 2.8–12) and 2.13 (0.46–7) g/min with the Piranha and VersaCut morcellators, respectively (p = 0.001). Similar retrieved tissue weight and catheter time were reported in both morcellators (Table 1). The median number of procedures done per blade was 22 (range: 20–25) and 18 (17–20) with the Piranha and VersaCut morcellators, respectively (p = 0.01). The median number of grams of prostate tissue retrieved per blade was 1499 (range: 1388–1539) and 943 (833–1248) with the Piranha and VersaCut morcellators, respectively (p = 0.04).
There was no significant difference between the two morcellators regarding perioperative biochemical changes and complications, apart from 5 bladder mucosal injuries in the VersaCut group (9%) (Table 2). Table 3 summarizes the tissue retrieval approaches used in contemporary series of different transurethral enucleation procedures. Data on preoperative prostate size, retrieved prostate weight, rate of tissue retrieval and possible complications related to the procedure of retrieval namely bleeding and bladder injury were tallied. Furthermore, findings of incidental prostate cancer and history of prior prostate surgery were depicted for possible impact on prostate tissue consistency.3-6,8,10-27
Discussion The transurethral enucleation of prostate adenoma carries the advantage of doing an anatomical based de-obstruction, which further to being complete is safer by tackling the vascular supply once it goes to the adenoma. Many competing techniques using different energy sources (electric and different lasers) to accomplish the enucleation procedure have been reported.2-5 However, retrieval of the adenoma after transurethral enucleation remains poorly evaluated. Transurethral resection of partially detached adenoma is not advantageous as it can induce more risk of bleeding, impaired visibility and is time consuming, especially for large prostates where the transurethral enucleation is superior to other minimally invasive surgeries. Morcellation of intravesical adenoma is currently the standard procedure following most transurethral enucleation procedures; however it is poorly evaluated. It is not complication-free and might require the surgeon to stage the procedure (secondary morcellation due to bleeding or blade malfunction).6 In our current study, we presented the current viable approaches used to retrieve the enucleated prostate ade-
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75.8 ± 29.7 NR
HoLEP
HoLEP
Piranha morcellator Piranha morcellator Morcellator (NR) Bipolar Mushroom
84.8 ± 34.9 51 (36–78) 59.9 ± 15.4 [34–89] 75 ± 38 77.3 [56–95]
ThulEP
ThulEP
ELEP
Greenlight LEP
PKEP
ThulEP
HoLEP
U; 54 ± 22 I; 53.6±20 43.5 ± 23 [37.3-76.4] 46.6 ± 25.2 [34.2-79.6]
HoLEP “up [U] & Inverse tech [I]”
Piranha morcellator
Unipolar Mushroom
Unipolar Mushroom
VersaCut morcellator
VersaCut morcellator
62 ± 34
HoLEP
Unipolar Mushroom
Unipolar Mushroom 83% VersaCut morcellator 17%
53.5 ± 20 [20–95]
114.6± 21 [100–230]
VersaCut morcellator OC 0.2% VersaCut morcellator OC 0.1%
VersaCut morcellator
VersaCut morcellator
VersaCut morcellator
VersaCut morcellator OC 0.3%
Unipolar Mushroom
Tissue retrieval approach
HoLEP
HoLEP
86.5 ± 65.4 [20–350]
G1; 94.3 G2; 79.3 G1; 93 ± 47 G2; 96 ± 46 B; 88.1 T; 100.4
G1 (HoLEP) G2 (2ry HoLEP) G1 (2ry HoLEP) G2 (HoLEP) HoLEP B and T
HoLEP
38 [20–70]
HoLEP
Procedure
51 ± 14.3
35 ± 22
32.20 ± 9.36
NR
NR
20.31 ± 6.62
11 (8–20)
NR
53.68 ± 29.9 [5 -147] 30 (16–51.25)
NR
NR
U: 14.3 ± 8.6 I: 6.4 ± 7.2
17.3 ± 14.5
NR
NR
19.3 ± 10.1 [4–45]
NR
G1: 16.9 G2: 16.6 G1: 19.8 ± 20 G2: 14.9 ± 11 B: 4.8 ± 2 T: 5 ± 3.6 17.6 ± 9.7 [5–65]
NR
37.6 ± 12.1
40.4 ± 10.6
NR
40 ± 27.5
32.6 ± 15.0 [10–80]
83.9 ± 21.9 [52–200]
G1: 64.5 G2: 52.6 G1: 61.7 ± 40 G2: 63.9 ± 42 B: 50 ± 49.5 T: 56 ± 41.8 46.7 ± 27 [7-152] 76 [0.4– 532.2] 78.6 ± 61.3 [10-350]
NR
Retrieved Retrieval time tissue weight (mean + SD (mean + SD [range] min) [range] g)
NR
NR
NR
2.6 (1.7–4)
NR
NR
NR
U: 1.93 ± 1.1 I: 4.03 ± 0.89
2.3 ± 1.5
NR
NR
4.07 ± 3.2
NR
G1: 3.81 G2: 3.16 G1: 4 ± 2 G2: 5 ± 2.5 B: 10.4 ± 24 T: 11.2 ± 11 2.8± 1 [0.9– 10.1]
NR
Retrieval rate (mean ± SD [range] g/min)
NR
1.5%
6.9%
NR
NR
NR
2.4%
NR
5%
4.4%
0.6%
0.8%
1.3%
G1: 2.7%
G1: 0.2% G2: 1.3
NR
Bleeding
NR
NR
Zero
NR
Zero
5.5%
1.4% (Mucosal) NR
14.1%
NR
NR
NR
3.6%
3%
5%
1.7%
10%
4.8%
NR
NR
NR
3.2%
T1a-b PCa (%)
NR
NR
NR
2.3% (Mucosal) 1.5% (Perforation)
5.7% (Mucosal)
NR
NR
NR
0.1% (Perforation)
4% (Mucosal)
0.3% (Perforation)
NR
0.7% (Mucosal)
NR
Bladder injury
Retrieval approach related Complication
RCT; randomized clinical trials, CS; case series, HoLEP; Holmium laser enucleation of the prostate, 2ndry HoLEP; after previous prostate surgery, ThulEP; Thulium laser enucleation of the prostate, Greenlight LEP; Greenlight laser enucleation of the prostate, ELEP; Eraser laser enucleation of the prostate, PKEP; Plasma kinetic enucleation of the prostate, NS; not specified, NR; not reported, NA; not applicable, PCa; prostate cancer, OC; open cystostomy; B: bilop; T: trilob; Piranha, Wolf Inc., Knittlingen, Germany; †VersaCut, Lumenis.
Kuntz et al 200417 (RCT) Vavassori et al 200818 (CS) Lee et al 201227 (CS) Zhang et al 201219 (RCT) Zhang et al 201219 (RCT) Rausch et al 20153 (RCT) Gross et al 20136 (CS) Hruby et al 201320 (CS) Brunken et al 20114 (CS) Liao et al 201226 (CS)
Kuntz et al 200216 (RCT)
Hochreiter et al 20028 (CS) Elshal et al10 2012 (CS) Jaeger et al11 2013 (CS) Wisenbaugh et al 201313 (CS) Placer et al 200914 (CS) Krambeck et al 201012 (CS) Abdel-Hakim et al 201015 (CS)
Study (RCT/CS)
Prostate size (mean ± SD [range] mL)
Table 3. Critical evaluation of prostate tissue retrieval approaches following different transurethral enucleation techniques in the contemporary series
Elshal et al.
NR NR NR 65.9 ± 20.8 116.2 ± 32 PKEP
Bipolar Mushroom
NR NR Bipolar Mushroom 110 [102–130] PKEP
118.2 ± 22.0
NR NR 64.2 ± 19.0 Bipolar Mushroom 113.8 ± 32
PKEP
PKEP
Piranha morcellator
108 [58–241]
16.5
6.56
2.9%
NR
NR
NR NR NR 56.4 ± 1 2.8 [32–102] Bipolar Mushroom
69.2 ± 13.5 [35–158] 132.6 [80–280] PKEP
RCT; randomized clinical trials, CS; case series, HoLEP; Holmium laser enucleation of the prostate, 2ndry HoLEP; after previous prostate surgery, ThulEP; Thulium laser enucleation of the prostate, Greenlight LEP; Greenlight laser enucleation of the prostate, ELEP; Eraser laser enucleation of the prostate, PKEP; Plasma kinetic enucleation of the prostate, NS; not specified, NR; not reported, NA; not applicable, PCa; prostate cancer, OC; open cystostomy; B: bilop; T: trilob; Piranha, Wolf Inc., Knittlingen, Germany; †VersaCut, Lumenis.
NR
1.25%
NR
2.8% NR
NR
NR NR NR 46.2 ± 19.1 Bipolar Mushroom 61.8 ± 18.7 PKEP
Luo et al 201422 (CS) Zhao et al 201024 (RCT) Geavlete et al 20135 (RCT) Zhu et al 201325 (RCT) Chen et al 201421 (RCT) Rao et al 201323 (RCT)
Tissue retrieval approach Procedure Study (RCT/CS)
NR
Bleeding
Bladder injury
T1a-b PCa (%) Retrieval approach related Complication
Retrieval rate (mean ± SD [range] g/min) Retrieved Retrieval time tissue weight (mean + SD (mean + SD [range] min) [range] g) Prostate size (mean ± SD [range] mL)
Table 3. Critical evaluation of prostate tissue retrieval approaches following different transurethral enucleation techniques in the contemporary series (cont’d)
Optimizing prostate tissue retrieval after HoLEP
noma following holmium laser enucleation. We compared safety and efficacy of two commercially available morcellators that have not been previously clinically compared. A single surgeon, with HoLEP experience with at least 30 morcellations using either morcellator, performed the procedures. A minimum of 20 cases are required to achieve morcellation efficiency.28 In an ex-vivo study, the efficiency of different morcellators were assessed. The Piranha morcellated 20 (range: 19.3–21.4) g/min, the VersaCut 10.8 (range: 8.2–13.1) g/min, Karl Storz prototype 9.8 (range: 7.9–10.76) g/min, and another Wolf prototype 38.6 (35.3–42.9) g/min.29 Another ex-vivo study looking at different efficiency parameters of the Piranha and VersaCut morcellators revealed similar suction power parameters (20.4 and 22.2 mL/s, respectively). Morcellating powers were (example with baked chicken meat) 2.5 and 6 g/min with Piranha and VersaCut, respectively.30 In the current study, the median rate of tissue retrieval was 6.2 (range: 2.8–12) and 2.13 (range: 0.46–7) g/min with Piranha and VersaCut morcellators, respectively. The literature demonstrated tissue retrieval rates of 2.6 to 6.5 and 1.9 to 11 g/min with Piranha and VersaCut morcellators, respectively (Table 3); however, there is little data on the details of morcellation in clinical reports of transurethral enucleation procedures. The safety of morcellator is a crucial part of the assessment in our current study; superficial bladder mucosal injury was reported in 9% of procedures with the VersaCut morcellator. Superficial bladder mucosal injury was reported in 1.4% and 0.7 to 5.7% with Piranha and VersaCut morcellators, respectively; there were bladder perforations with the VersaCut morcellator (range: 0.1–1.5%) (Table 3). In their ex-vivo study, Cornu and colleagues showed that the blade of the Pirhana morcellator was under visual control, whereas the distal part of the cutting blade was out of vision control with the VersaCut.30 The efficiency of tissue retrieval by a morcellator is a sum of multiple variables, including prostate tissue consistency, suction power, and morcellator blade. Prior prostate surgery and histopathological features of the adenoma probably affect prostate tissue consistency. Other non-morcellation approaches have been used in many of the reported transurethral enucleation techniques, as a routine practice (like using mushroom technique after most bipolar enucleation techniques5,23,26 and, to a lesser extent, after HoLEP8,16,17) or occasional in cases of morcellator malfunction or for exceptionally huge adenomas where some surgeons perform an open cystostomy for adenoma extraction.10 The morcellator action is to cut and suck. Most of mechanical problems reported in this study were related to suction. In the Piranha morcellator, suction depends on creating negative pressure within a vacuum bottle. Problems
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occurred secondary to leak of negative pressure from the vacuum bottle/ tubing set. This requires the surgeon to stop to recreate the required negative pressure. In the VersaCut morcellator, suction depends on a high-suction roller pump; obstruction of the tubing set with large tissue piece causes malfunction of the pump and significantly reduces suction power. This also requires the surgeon to stop and reverse direction of flow for a while to clean the tubing set. Lastly, regarding the technique of transurethral morcellation, we used the conventional upward technique. A modification of the technique to increase morcellation efficiency and to lessen the incidence of bladder injury is called “the inverse technique.”27 It entails sucking the adenoma toward the blades then inversely rotating the nephroscope and the blades, with the blade openings pointing inferior toward the bladder and superior to the prostate tissue. Lee and colleagues reported a higher rate of tissue retrieval with their technique using the VersaCut morcellator.27 Superficial (7.1% and 0.9%) and deep bladder injuries in (5.9% and 0.3%) were reported in conventional and inverse techniques, respectively (Table 3). Our study has its limitations. In terms of evidence, this study lacks randomization. However, we found that randomization was not practical for an in depth evaluation of all aspects of morcellation, including reusable blade efficiency (e.g., surgeons prefer using new or minimally used blades when tackling significantly large glands). So, we assigned 3 blades for each morcellator group for the study, with careful reporting of all peri-procedure parameters.
Conclusion Morcellation with the Piranha morcellator was the most efficient and safe way to retrieve tissue following transurethral enucleation of prostate adenoma during BPH treatment. Detailed reporting of the morcellation step is recommended in any report of a transurethral enucleation technique. Competing interests: The authors declare no competing financial or personal interests.
This paper has been peer-reviewed.
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Correspondence: Dr. Ahmed M. Elshal, Urology and Nephrology Center, Mansoura University, Mansoura, Dakahlia Governorate, Egypt; [email protected]
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